Washington Contact Preference Form for Birth Parents of Adopted Children (DOH 422-110)
Official state formAdoptionForm DOH 422-110Free downloadLast verified November 10, 2026
A birth parent completes this form to state whether they want contact with the adoptee and whether a noncertified copy of the original birth certificate may be released to the adoptee. The Center for Health Statistics at the Department of Health places it in the sealed adoption file.
Who can use this form
- A birth mother or parent, or a birth father or parent, of an adopted child
- The birth parent completes and signs the form under penalty of perjury
- The form expires upon the death of the birth parent, and can be replaced with a new one at any time
What to send with it
- The completed and signed contact preference form
- A completed Birth Parent Medical History form (DOH 422-111), which the form says must also be completed
Where to send it
- Mail to
- Center for Health Statistics PO Box 47814 Olympia, Washington 98504-7814
- State fee
- Not provided
- Typical processing
- Not provided
- Form revision
- August 2018
- Source
- Official government page